Another Home Health “Compare” to Make

In reviewing many home health denials, medical reviewers often identify patterns that highlight areas of focus. One of these patterns relates to therapy requirements.

Agencies must have orders for therapy and show therapy service is skilled, reasonable, and necessary. In addition, the requirement for a 30-day therapy reassessment must occur. And it is this requirement where too many home health agencies fail.

What is missing?

From a recent explanation of a partial home health denial of therapy service:

“Documentation does not contain a completed 30 day Physical Therapy reevaluation. The reassessment is missing documentation of comparison of the prior evaluation. Therefore, Physical Therapy Billed 9/18/17, 9/21/17, 9/26/17, 9/28/17, 10/3/17, 10/10/17, and 10/12/17 are not covered.”

CMS requires in both 42 CFR 409.44(c)(2)(i)(B) and (C) that at least every 30 days a reassessment is completed by each therapy discipline providing service: “(B) At least every 30 calendar days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient in accordance with § 409.44(c)(2)(i)(A). Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the needed therapy service and functionally reassess the patient in accordance with § 409.44(c)(2)(i)(A) at least every 30 calendar days.

When are therapy visits covered?

(C) As specified in paragraphs (c)(2)(i)(A) and (B) of this section, therapy visits for the therapy discipline(s) not in compliance with these policies will not be covered until the following conditions are met:

  1. The qualified therapist has completed the reassessment and objective measurement of the effectiveness of the therapy as it relates to the therapy goals. As long as paragraphs (c)(2)(i)(C)(2) and (c)(2)(i)(C)(3) of this section are met, therapy coverage resumes with the completed reassessment therapy visit.
  2. The qualified therapist has determined if goals have been achieved or require updating.
  3. The qualified therapist has documented measurement results and corresponding therapy effectiveness in the clinical record in accordance with paragraph (c)(2)(i)(F)of this section.”

Anything else required?

As a matter of fact, yes. Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02, Chapter 7, Section 40.2.1 (b.)(ii) also requires this reassessment:

“ii. Reassessment at least every 30 days (performed in conjunction with an ordered therapy service)

  • At least once every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally reassess the patient, and compare the resultant measurement to prior assessment measurements. The therapist must document in the clinical record the measurement results along with the therapist’s determination of the effectiveness of therapy, or lack thereof.” [emphasis added]

Now—what are agencies missing that gets them the home health denial?

Agencies complete the reassessment. They have one for each therapy discipline providing service. They complete it within 30 days of last assessment. However, they do not “compare the resultant measurement to prior assessment measurements.”

Above all, the clinical records must clearly show these comparisons. It is not enough to document current status of the reassessment and have the prior assessment in the clinical record. There must be a documented comparison of the reassessment findings, which is then used to assess progress. Similarly, the comparison highlights need to amend or change the plan of care.

Too many Electronic Medical Record (EMR) systems fail to cue the therapist to make this comparison or are not configured to make the comparison. As a result, some leave this as a narrative statement and some make no mention at all of comparing the reassessment findings to the prior assessment findings.

Eliminating this denial.

Therefore, to eliminate this unnecessary denial, home health agencies should:

  • Evaluate their current EMR to see what it contains relative to this requirement.
  • Inservice therapy and Quality Assurance staff on this requirement so that the required content can be included in the medical record timely.
  • Institute this as a reviewed item during record review and prior to final billing. If the reassessment is found to be deficient with the comparison, a communication/late entry note clarifying the content can be admitted to the record prior to final billing.

CMS puts enough pressure on home health agencies to make a favorable comparison (Home Health Compare): do not forget to have your therapists make their required comparison to avoid denials. Likewise, do not forget – this also applies to many Medicare Advantage plans that seem especially attuned to this issue when reviewing records.


QIRT is prepared to support your agency via readiness audits, checklists, and a team of experts. Find out more.

By Joe Osentoski, BAS, RN-BC, QIRT Reimbursement Recovery and Appeals Director

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